Surgical tray reduction for cost saving in pediatric surgical cases: A qualitative systematic review

[Implementing an operating room pharmacy satellite in an university hospital]

OBJECTIVES

An operating room pharmaceutical unit centralizes medical devices and drugs for various surgical specialities. The aim of this work is to present the methodology used in our establishment to set up the operating room pharmaceutical unit.

METHODS

This approach involved the formation of multi-professional working groups. The needs of operating theatres were defined based on an analysis of healthcare product consumption and stock inventories. Material sheets were defined for each procedure. On the basis of simulations, material supply arrangements were selected, specifying material flows, equipment, workstations and information systems.

RESULTS

Over 3200 healthcare product references were identified and 862 equipment files were created. Local stocks have been limited to medical trolleys for nursing staff. Emergency operating packs have been deployed for unforeseen operations. Cabinets have been dedicated to transporting re-sterilizable medical devices, and carts have been purchased for programmed operating packs. The equipment is made available by logistics agents and pharmacy assistants under pharmaceutical responsibility.

CONCLUSIONS

This innovative approach is a model for facilities desiring to centralize and secure the logistics of healthcare products in the operating room. Ongoing adjustments will be required to meet new operating rooms needs.

Using Preference Cards to Support a Thoughtful, Evidence-based Orthopaedic Surgery Practice

INTRODUCTION

When orthopaedic surgeons begin or relocate their careers, they must communicate effectively about their instrumentation and equipment needs. 'Preference Cards' or 'Pick Lists' are generated by and for individual surgeons at the time of hire and can be updated over time to reflect their needs for common cases. Currently, such decisions are made without formal guidance or preparation.

BODY

Surgeons must consider and plan for their operating room needs. Health system and industry factors affect these decisions, as do surgeons' unique interests, preferences, and biases. Orthopaedic surgeons currently face challenges: formal education is deficient in this space, material and reprocessing costs are not transparent, relationships and contracts with industry are complex, and few health systems have mechanisms to support preference card optimization. This complex landscape influences utilization decisions and leaves opportunities for integration, collaboration, and innovation.

SUMMARY

Choices about instrument and resource utilization in the OR have wide-reaching impacts on costs, waste generation, OR efficiency, sterile processing, and industry trends. Surgeons and their teams have much to gain by making intentional choices and pursuing both individual and systematic improvements in this space.

Team Approach: Improving Orthopaedic Operating Room Efficiency

The cost of surgical care accounts for almost one-third of all health care spending in the United States. Within health care spending, the operating room (OR) is one of the largest health care costs during a perioperative episode of care. Efficiency in the OR has been associated with increased productivity, safety, and quality of care. However, multiple sources of delays can contribute to inefficiency, and improving efficiency in the OR requires a systematic approach to identify and address each issue. We report on the case of a process improvement initiative implemented in a large academic institution to improve OR efficiency in outpatient orthopaedic cases, and we discuss the lessons learned through this program. Optimizing workflow in the OR requires a multidisciplinary team approach consisting of clinician leaders with common goals and open discussion regarding the needs of each team member, including circulating nurses, surgical nurses/technologists, and anesthesiologists. Our experience highlights the importance of practical, clinician-driven changes that are supported by administrative engagement, resources for staffing and equipment, and institutional flexibility, which are required to implement systemic changes to address and improve efficiency in the OR.

Adapting lean methodology towards surgical tray rationalisation in inguinoscrotal day case surgery in the republic of Ireland

INTRODUCTION

Lean methodologies have been used successfully in both industry and healthcare to reduce waste. The operating room (OR) and central supplies department (CSD) are areas associated with high hospital costs. The aim of this study was to employ Lean methodologies to support the rationalisation of surgical trays in paediatric inguinoscrotal surgery in order to reduce instrument wastage, processing times and overall costs in a European setting.

METHODS

This was a prospective, pilot observation and implementation study using Lean methodology including DMAIC (Define, Measure, Analyse, Improve and Control) cycles. Relevant tray set-up included trays for boys ≥12 months age undergoing open elective inguinoscrotal surgery. A comparative analysis of two phases, pre and post-standardization was then carried out with respect to operating times, instrument set-up times, tray weights, and costs. Instruments that were used <40% of the time were eliminated from the surgical tray.

RESULTS

Rationalization of the inguinoscrotal tray led to a 34.7% reduction in tray size, with a concomitant time-reduction of >2 min per case. The average overall instrument utilisation rate increased from 56% to 80% across users. Cost savings were projected at €5380.40 per annum based on current changes. There were no differences in operative time, or adverse outcomes.

DISCUSSION

At the hospital level, the reduction in variation, and rationalisation of this single surgical tray could lead to both operational (Tray assembly process; Operating rooms; Ergonomic functionality) as well as economic (Sterilisation; Instrument repair; Purchases) financial and ergonomic improvements for the healthcare system. The reduction in time taken to count and sterilise instruments can lead to a potential manpower saving involving a redistribution of activities to other areas which may require them.

CONCLUSION

Surgical tray rationalisation is emerging Lean concept with overlap across a number of specialities, and represents a technique by which to manage costs, and improve supply chain efficiency without any adverse effect in patient healthcare outcomes.

Improving perioperative management of surgical sets for trauma surgeries: the 4S approach

Background

The perioperative management of the surgical instruments and implants that comprise sets for trauma surgeries has been identified as a complex and resource-intensive activity due to non-standardized inventories, redundant surgical instruments and unnecessary sterilization cycles. The 4S Intelligent Trauma Care program aims to improve perioperative management and thereby reduce environmental impact by utilizing standardized inventories, a sterile implant portfolio, a barcode that enables a digital safety certification, and a digitized restocking service.

Objective

The objective of this study was to investigate the impact of the introduction of the 4S program for the management of surgical sets in open reduction internal fixation (ORIF) trauma surgeries.

Methods

This was a single-center, quality improvement study of ORIF trauma surgeries, comparing the current practice (30 procedures) to the procedure following the introduction of the 4S program (30 procedures). The primary outcome was the proportion of procedures requiring only one sterilization cycle. Secondary outcomes were the number of sterilization cycles per procedure, set processing time across departments, total set processing costs, number of missing or damaged implants, number of cleaning cycles per procedure, time taken to assemble containers for sterilization, number of containers entering the autoclave per procedure, environmental impact, number of baskets entering the cleaning machine per procedure, and staff satisfaction.

Results

Introduction of the 4S program resulted in a reduction in the mean number of sterilization cycles required from 2.1 to 1.0 (p < 0.001). In the current practice, only 30.0% of procedure sets were sterilized within one cycle, compared to 100.0% following introduction of the 4S program (p < 0.001). A reduction in the mean set processing time of 24.1% in the OR and 35.3% in the sterilization department was observed. Mean set processing costs for the current practice were €81.23, compared to €50.30 following introduction of the 4S program. Furthermore, following the introduction of the 4S program, procedures were associated with significant reductions in water and electricity usage, and increased staff satisfaction.

Conclusions

This quality improvement study demonstrates the substantial time and cost savings, positive environmental impact and staff satisfaction that could be achieved by streamlining surgical set management through the 4S program. To our knowledge, this is the first study of this type and our findings may be instructive to other hospitals and surgical specialties.

Releasing Operating Room Nursing Time to Care through the Reduction of Surgical Case Preparation Time: A Lean Six Sigma Pilot Study

Healthcare systems internationally are working under increasing demand to use finite resources with greater efficiency. The drive for efficiency utilises process improvement methodologies such as Lean Six Sigma. This study outlines a pilot Lean Six Sigma intervention designed to release nursing time to care within a peri-operative environment; this was achieved by collaborating with stakeholders to redesign the process for laparoscopic hernia surgical case preparation (set up) material. Across 128 laparoscopic hernia surgical cases, the pilot resulted in a 55% decrease in overall nursing time spent in gathering and preparing materials for laparoscopic hernia surgical cases, with a corresponding reduction in packaging waste. The major impact of releasing nursing time to care within busy Operating Room environments enabled nurses to focus on continuing to deliver high-quality care to their patients and reduce pressure expressed by the Operating Room nurses. The results have led to an ongoing review of other surgical procedures preparation to further release nursing time and will be of interest to perioperative teams internationally.

Reducing Supply Cost by Standardization of Surgical Equipment in Laparoscopic Appendectomy

BACKGROUND AND OBJECTIVES

Compensation for increased medical services from reimbursement systems are sometimes insufficient. Generally, appendectomies are performed by individual surgeons with their preferred instrument. Surgical equipment standardization is known to reduce medical cost without compromising patient safety. Hence, we investigated the effectiveness of surgical equipment standardization to reduce the required operative cost for laparoscopic appendectomy at our tertiary hospital.

METHODS

Nine surgeons at our tertiary hospital agreed to use standardized equipment for laparoscopic appendectomy. We compared outcomes among patients who underwent laparoscopic appendectomy between December 2012 and June 2013 before standardization (control group) and between August 2015 and February 2016 after standardization. Participating provider and staff convenience was also surveyed using a questionnaire.

RESULTS

The implementation of standardized equipment for laparoscopic appendectomy decreased intraoperative supply cost from US $552.92 to $450.17. Operative times also decreased from 73.8 to 53.3 minutes. However, hospital days and complication rates remained unchanged. Participants responded that surgical equipment standardization improved efficiency in the operating room and reduced the cost.

CONCLUSION

Surgical equipment standardization in laparoscopic appendectomy is effective in reducing intraoperative supply cost without compromising patient safety.

Data Analysis of Plastic Surgery Instrument Trays Yields Significant Cost Savings and Efficiency Gains

PURPOSE

Inpatient surgery costs have risen 30% over the past 5 years, and the operating room accounts for up to 60% of total hospital operational expense. On average, only 13.0% to 21.9% of instruments opened for a case are used, contributing to significant avoidable reprocessing, repurchase, and labor expense.

METHODS

A comprehensive review of 40 major instrument trays at UNC Rex Hospital was conducted using a technology service (OpFlow; Operative Flow Technologies, Raleigh, NC). Among the full scope of the project, the general plastics tray and breast reconstruction tray were evaluated for the plastic surgery service line over a 3-month period. Intraoperative data collection was performed on the exact instruments used across a standard breadth of cases. Data analytics were conducted stratifying instrument usage concordance among surgeons by tray and procedure type. After a surgeon-led review of the proposed new tray configurations, the optimized versions were implemented via a methodical change management process.

RESULTS

A total of 183 plastic surgery cases were evaluated across 17 primary surgeons. On average, the instrument usage per tray was 15.8% for the general plastics tray and 23.5% for the breast reconstruction tray. After stakeholder review, 32 (45.1%) of 71 instruments were removed from the general plastics tray and 40 (36.7%) of 109 were removed from the breast reconstruction tray, resulting in a total reduction of 2652 instruments. This resulted in a decrease of 81,696 instrument sterilization cycles annually. The removal of the instruments yielded an estimated cost avoidance of US $163,800 for instrument repurchase and US $69,441 in annual resterilization savings. The instrument volume reduction is projected to save 383.5 hours of sterile processing personnel time in tray assembly annually.

CONCLUSIONS

An analytics-driven method applying empirical data on actual case-based instrument usage has implications for better efficiency, improved quality, and cost avoidance related to instrument repurchase and sterile processing. Given increasing cost constraints and the transition to value-based care models, leveraging a technology-based solution enables meaningful change in the sterile processing department as a source for cost reduction and quality of care improvement.